=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275842452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANNA B. SHIMELFARB M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48-50 FAIRFIELD STREET
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-8511
-----------------------------------------------------
Fax | 973-744-6356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 95000-2454
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19195-2454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-218-0450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA09722100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------